Nearly seven months after a loss hearing to determine how much money Dr. Jorge Zamora Quezada and his clinic made through a healthcare fraud scheme, questions lingered about those funds, preventing the sentencing phase of the case to proceed.
During a hearing held Thursday, U.S. District Judge Ricardo Hinojosa said he still had questions about how much money in insurance claims Zamora Quezada’s clinic had filed with insurers with regard to patients who were diagnosed with rheumatoid arthritis.
Hinojosa instructed the attorneys for the government to provide a list of patients who were diagnosed with rheumatoid arthritis by Zamora Quezada or another physician working at his clinic, the amount of the claim that was filed to insurers for that patient and how much the clinic received from that claim.
The government will also have to provide any evidence it has that the listed patients were misdiagnosed.
In January 2020, Zamora Quezada, an Edinburg-based rheumatologist, was convicted on one count of conspiracy to commit healthcare fraud, seven counts of healthcare fraud, and one count of conspiracy to obstruct justice.
In October, the court held a loss hearing to determine how much money insurers and patients lost from the scheme.
Attorneys representing the government made the case that the doctor received $29 million from insurers based on the testimony of a certified public accountant who applied a “misdiagnosis rate” to Zamora Quezada’s pool of patients.
But another CPA who testified on behalf of the defense calculated that $1.89 million was paid to Zamora Quezada and his clinic for claims that were tied to a diagnosis of rheumatoid arthritis.
Stephen Lee, one of the doctor’s attorneys, said Thursday he felt the government had plenty of opportunities to provide evidence of specific patients during the loss hearing. Instead, Lee argued, the government only provided a large number of people assumed to have been wrongly misdiagnosed simply because they called a hotline.
The only patients for which the government had met the burden of proof, Lee argued, were those listed in the indictment against the doctor and for which he was convicted, and a few others for which the government had provided medical records.
But the judge pointed out there was evidence that Zamora Quezada had instructed other staff in his clinic to diagnose patients with rheumatoid arthritis and that the only way they were going to get to the bottom of this issue was to know which claims filed with insurers were tied to a rheumatoid arthritis diagnosis. A percentage of that, likely 25%, is what the clinic was actually paid for those claims and that would be the actual loss, the judge said.
“The amount is the one that drives the (sentencing) guidelines the highest here,” the judge said.
Hinojosa gave the government 20 days to respond to his questions after which the defense will have an opportunity to respond.
